Guidelines for patients with Severe Closed Head Injury and IICP

 

Clinical judgment should be used to individualize patient management.

 

Definitions:

Severe Head Injury: 

-         GCS 8 or less after initial resuscitation with or without abnormal CT scan findings on admission.

-         Table I: Pediatric GCS (for patients under 4 y/o)

Eye Opening

Verbalization

Motor Response

4: spontaneous

5: coos, babbles

6: normal spontaneous movement

3: to voice

4: irritable

5: withdraws to touch

2: to pain

3: cries to pain

4: withdraws to pain

1: no response

2: moans to pain

3: decorticate posturing

 

1: no response

2 decerebrate posturing

 

 

1: no response

 

Normal ICP

-         Table II: Normal ICP:

Age

ICP

0-2 years

1.5-6 mmHg

2-10 years

3-7 mmHg

10-18 years

<10 mmHg

 

Criteria for ICP monitoring:

-         GCS 8 or less and abnormal CT scan on admission.

-         Patients with GCS 8 or less on admission who have a normal CT scan should have a documented neurological exam an least every six hours (in addition to hourly GCS score) to reevaluate the need for repeat CT scan and/or the placement of an ICP monitor.

 

Cerebral Perfusion Pressure:

-         CPP =  MAP-ICP (If CVP>ICP, then CPP=MAP-CVP)

-         Because cerebral pressure/flow autoregulation is lost in many patients after head injury, normal CPP is required to prevent hypoperfusion of at risk areas of the brain. (Table III). If not possible, a CPP > 55 mm Hg should be maintained at all times. In neonates, a CPP of 40 mm Hg is acceptable.

-         Table III: Average Blood Pressure and Cerebral Perfusion (CPP) values.

 

Age

 

SBP/DBP

 

MAP (range)

 

CPP

1-3 days

64/41

50 (38-62)

40

1mo-2 yr.

95/58

72 (65-86)

62

2-5 yr.

101/57

74(65-85)

64

6-7 yr.

104/55

71(65-91)

61

8-9 yr.

106/58

74(65-94)

64

10-11 yr.

108/60

76(65-96)

66

12-13 yr.

112/62

79(65-98)

69

14-15 yr. Boys

                Girls

16-18 yr. Boys

                Girls

116/66

112/68

      121/70

110/68

      

   83(65-103)

83(65-98)

  87(65-104)

82(65-98)

 

73

73

77

72

 

 

 

LOW CPP

(See Table III)
 
Algorithm:

 

 

 


              

LOW MAP

(See Table III)
 

ICP > 20
 

                                                      

 

 

 

 


                                              

 


                                                     

 

 

 


流程圖: 替選處理程序: Low SVO2 (＜50%): start dopamine. In no response, add epinephrine 流程圖: 替選處理程序: High or normal SVO2: start norepinephrine or phenylephrine

Mannitol: 0.25g/kg may repeat q3hr if serum Osm<320 and euvolemic (2)
 
                                                                                                                            

 

                                                                                          

 

 

 

 

 

 

 

 

 

 

 


(1) Watch for hypotension. May need fluid bolus/inotropic support.

(2) Consider increasing dose up to 1g/kg/dose(5ml/kg in 20% maniton) q3h as long as patient euvolemic and serum Osm<320. Consider Lasix 1mg/kg 15 min after mannitol dose.

(3) May need pavulon 0.01mg/kg/dose to prevent shivering. The use of hypothermia should be reevaluated after 36 hours and every 24 hours thereafter. Make sure patients are getting tylenol and or ibuprofen before using pavulon.

(4) If persistently low CPP despite above therapeutic interventions, the use of pentobarbital or thiopental burst suppression may be discussed. Therapeutic levels do not accurately reflect physiologic effect. The method is: Thiopental 20 mg/kg over 1 hour followed by 10 mg/kg/hr for 6 hours, then 3 mg/kg/hr by continuous infusion. Hypotension is a common side effect, therefore fluid resuscitation and/or inotropic support is frequently needed.